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					                                       MENTOR APPLICATION
                                                 and Program Explanation
                                                       Giving At-Risk Youth
                                                        A Second Chance
 P.O.Box 3209 San Luis Obispo CA 93404-3209 * 1-800-926-0643 * Mentor Coordinator 1-805-782-6886 * Fax 1-805-782-6885

Students: Please give this Mentor Application to someone that you trust and look up to, someone who will be a friend, role model,
and a good listener. The mentor must be the same sex as you, at least 25 years old, and not a close relative, or living in the same house.
If you have questions, call the number above.

Mentor Applicant: **All mentors must submit proof of auto insurance, and a copy of current driver’s license. **
Your completed application should be turned in with the student’s application. We need both of the attached character references filled
out by someone who knows you well (Not a relative or spouse)      ALL MENTOR INFORMATION WILL REMAIN
CONFIDENTIAL. The student does not need to see your application. Your application can be in a sealed envelope for privacy
purposes.

Mentor Program Explanation                     check out our website for more information: www.ngycp.org/ca

Thank you for considering being a mentor for a Grizzly Youth Academy cadet. Grizzly Youth Academy is a unique opportunity for a
young person who has dropped out, or is struggling in school. It truly is a “second chance” to turn a life around. A very important
part of this program is the involvement of mentors. When a cadet has a mentor who is committed to help him succeed, he or she is
much more likely to finish the program and return to his/her community as a productive citizen. We know that your time is precious,
but this opportunity is life changing…..for both of you. Please call if you need more information. Here is a brief description of what is
involved in the Mentor Program at GYA.

       Each student must provide ONE mentor application to be accepted into the program. A “friendly match” where the cadet and
        mentor know each other is much more productive. The mentor must be over 25, the same sex as the student, and not a close
        family member or living in the same house.

       The mentor will provide a completed application, proof of auto insurance, and copy of current driver’s license. Once the
        student is accepted we will send you a “Live Scan” fingerprint submission form for the purpose of a criminal background
        investigation. DO NOT SEND A FINGERPRINT CARD. The Dept. of Justice does not accept them anymore.

       The mentor will attend one training/matching ceremony at Camp San Luis Obispo after the cadet passes pre-challenge.
        These trainings are offered on a Friday, or Saturday, or Sunday for your convenience.

       Mentors and cadets will be writing to each other during the residential phase.     Cadets will be making phone calls to mentors
        after they have been “matched”.

       Mentors are invited to visit their cadets on specified days. Visits are not mandatory, but encouraged.

       The cadets will develop a “life plan” (their goals for the future) while at Grizzly and the mentors will get a copy.

       The mentor and cadet must live in the same community when the cadet returns home to maintain the relationship.

       When the cadet graduates and returns home, he/she is required to be meeting with the mentor at least two times a month,
        preferably face to face, for the 12 month post residential period.

       Mentors will play an important role encouraging the cadet to enroll in school, get a job, and stay on the right path. (these are
        requirements for the post-residential phase)

       The mentor will send a report to the Academy once a month for 12 months following graduation. This is a one page sheet with
        check off boxes for your convenience. It can be mailed, faxed, phoned, or e-mailed to GYA.

       Grizzly Youth Academy must report each month to the Congress of the United States to show that this program is making a
        difference. The mentor report is critical to this process.

       Most of all, the mentor and cadet should have a little fun and develop a relationship that is rewarding for both.

                                             I have read the Mentor Program Explanation

  Mentor Signature_______________________________ Student Signature_______________________________ Date_______
                                                  Grizzly Youth Academy
                                                Volunteer Mentor Application
Dear Mentor: Please print clearly.           This information is confidential. The entire application with proof of auto insurance, and
copy of driver’s license can be sealed in an envelope for privacy purposes, but should accompany the student application.

Today’s Date:______________                         PLEASE PRINT CLEARLY - All fields are required information

Full Name_____________________________________________________ Sex_____ Ethnicity_______ Marital Status__________

Date of birth______________________________           Age____________         Social Security Number _________________________

Drivers License Number: ________________________________Auto Insurance Company: _________________________________

Students must be able to contact the mentor. Home Phone:(             )____________________Cell (          )___________________

E-Mail Address____________________________________________Fax #:_________________ Pager # ____________________

Home Mailing Address:_________________________________________________________________County:________________
                           Street address              Apt #           City                Zip Code


Name of student you will be mentoring:____________________________________ Relationship to Student:

Why do you think you would be a good mentor for this student?

How many miles do you live from the student’s home?              Do you understand that this commitment is for 17 ½ months?______

Present Employer                                                       Employer Address:

Occupation:____________________ _____MAY WE CALL YOU AT WORK?____ Work Phone:_______________ Ext:______

How long employed?_________Full or part time________Other Volunteer Commitments:

Highest educational level achieved: High School____ Technical Training ___ College/ University ____ Other_________________

Past experience with Youth/Children

Health: Poor       Fair____ Good ____ Excellent         Any special concerns or physical limitations?

Please explain your present use of alcohol or any other drugs.

Please explain your past use of alcohol or any other drugs

Please list two references that we can call. (not relatives): Also give the two attached forms to two other people.
                                   Work # ______________________                                       Work#________________
1. Name                            Home #.                           2. Name                           Home #.

What attitudes and beliefs are of special importance to you?

Interests and hobbies:

Have you previously been a GYA mentor____ Student Name__________________ Has your child attended GYA?____ Name_________________
Have you ever been involved in, investigated for, arrested and/or convicted of any crime?________________________
Have you ever been convicted of a sex-related crime? Yes ____ No_____ When________________________________________
Have you ever been convicted of a crime involving violence, or the threat of violence? Yes___ No___ When____________________
Have you ever been convicted of a crime involving drugs and/or alcoholic beverages? Yes___ No___ When____________________
Are any of these crimes a felony?_________________________________________________________________________________
Crime                                         When                                 Please Explain:


Are you on probation___ or parole___ ?         Have you ever been on probation___ or parole?_________________________________
If yes to the above questions, please explain.________________________________________________________________________
Contact the Mentor Coordinator if you have concerns regarding past offenses and your eligibility as a mentor.               Anything
discussed will remain strictly confidential.        (805) 782-6886

                              AUTHORITY FOR RELEASE OF INFORMATION AND RECORDS
                              AND RELEASE OF LIABILITY (permission for background check)

         In accordance with the Privacy Act of 1974 or other applicable law, I hereby authorize and consent to the release of
information and records bearing on my personal history, arrest, and convictions, in any way to special agents of the Department of
Defense or California Military Department. Upon request, a copy of this signed statement may be furnished to the school, present or
former employer, criminal justice agency or other person furnishing such information or record. This information will be used for the
purpose of determining my eligibility as a participant as a Mentor with the Grizzly Youth Academy.

Mentor’s Name:                                                             County of Residence

S. S. #:___________________________ Driver’s License #:____________________________State:

Place of Birth:                                                           Date of Birth:

Previous Addresses (last 5 years):


                                                     Mentor Liability Release

The term “GYA” refers to, and is meant to include the State of California, the California National Guard, the California Youth
Challenge Program, and the Grizzly Youth Academy for purposes of the release:

         I understand and agree that I will be the one actually spending time with my matched cadet, and that I must exercise care in
supervising my cadet while we are together. I also understand and agree that I am not a “GYA” agent, and that I am responsible for
choosing and conducting all activities with my cadet, and that “GYA” does not retain any power to control how these activities are
conducted. I therefore agree that “GYA” will not be liable for, and I agree to hold “GYA” harmless from all liability, causes of action,
and losses imposed on it in any way related to or arising out of this mentoring agreement, including, but not limited to, liability for
personal injuries, whether the liability, cause of action, or loss is caused by my negligence, or “GYA” negligence or otherwise. I
further release “GYA” from any and all liability claims, demands, actions, or causes of action whatsoever arising out of any damage,
loss, or injury I might incur while participating in any of the activities contemplated by this mentoring agreement, whether such
damage, loss or injury is caused by the negligence of “GYA”, its officers, agents, servants, employees, or otherwise. I understand that
“GYA” will release my name, address, and phone numbers to other mentors for the purpose of coordinating mentor/cadet activities,
unless otherwise specified by me.

MENTOR SIGNATURE:_____________________________ DATE:________
                                                    CALIFORNIA NATIONAL GUARD
                                                     GRIZZLY YOUTH ACADEMY
                                                       CAMP SAN LUIS OBISPO
                                                            P. O. BOX 3209
                                                    SAN LUIS OBISPO, CA 93403-3209
                                                     (805) 782-6886 or 1-800-926-0643
                                                            Fax: (805) 782-6885


                         Mentor Character Reference                              (not for student)
Dear Mentor Applicant: Please give this form to a person who is not related to you and would know something about
your character (over 21, not a relative).

Dear_________________________________________
      (Name of person giving reference - please print)

                                                               has applied for volunteer work to be a mentor for
    (Prospective Mentor applicant’s name - please print)

_____________________________________________ , an applicant to the Grizzly Youth Academy
   (Prospective Student’s Name -    please print)
Grizzly Youth Academy, which focuses on the needs of “At Risk” Youth.
He/She is being considered for a match with this student in a one-to-one relationship. Please help us learn whether this person is
suited for this type of work. We would be grateful if you would answer the questions on this form as fully and carefully as you can.
Information received will be kept in confidence. This form can be faxed for confidentiality if you prefer.

How long have you known the MENTOR applicant?                          How do you know this person?

Does the MENTOR applicant have a good home relationship?                 Does he/she work well with others?


Please rate the prospective MENTOR in the following areas.
                                                Excellent         Good        Average        Poor        Unknown

            Personal Habits
                                                     _____      _____        _____        _____         _____
            Character
                                                     _____      _____        _____        _____         _____
            Compassion for others
                                                     _____      _____        _____        _____         _____
            Completes commitments
                                                     _____      _____        _____        _____         _____
            Emotional stability
                                                     _____      _____        _____        _____         _____
            Maturity level
                                                     _____      _____        _____        _____         _____
            Receives constructive criticism
                                                     _____      _____        _____        _____         _____
            Health
                                                     _____      _____        _____        _____         _____
Is there anything about this person that we should know before matching him/her as a mentor with this young person?



If you were in our position, would you, without hesitation, consider using this person as a Mentor for an “At Risk” Youth?



                                   No reference will be valid unless signed and with phone numbers.

Signature of person making recommendation                                                                     Date

Home Phone (         )                                                          Work Phone (        )
                                                    CALIFORNIA NATIONAL GUARD
                                                      GRIZZLY YOUTH ACADEMY
                                                         CAMP SAN LUIS OBISPO
                                                             P. O. BOX 3209
                                                     SAN LUIS OBISPO, CA 93403-3209
                                                      (805) 782-6886 or 1-800-926-0643
                                                             Fax: (805) 782-6885


                         Mentor Character Reference                              (not for student)
Dear Mentor Applicant: Please give this form to a person who is not related to you and would know something about
your character (over 21, not a relative).

Dear_________________________________________
      (Name of person giving reference - please print)

                                                              has applied for volunteer work to be a mentor for
    (Prospective Mentor applicant’s name - please print)

_____________________________________________ , an applicant to the Grizzly Youth Academy
   (Prospective Student’s Name -    please print)
Grizzly Youth Academy, which focuses on the needs of “At Risk” Youth.
He/She is being considered for a match with this student in a one-to-one relationship. Please help us learn whether this person is
suited for this type of work. We would be grateful if you would answer the questions on this form as fully and carefully as you can.
Information received will be kept in confidence. This form can be faxed for confidentiality if you prefer.

How long have you known this applicant?                       How do you know this person?

Does the Mentor applicant have a good home relationship?                 Does he/she work well with others?________

Please rate the prospective Mentor in the following areas.
                                                  Excellent       Good        Average        Poor        Unknown

            Personal Habits
                                                    _____       _____        _____        _____         _____
            Character
                                                    _____       _____        _____        _____         _____
            Compassion for others
                                                    _____       _____        _____        _____         _____
            Completes commitments
                                                    _____       _____        _____        _____         _____
            Emotional stability
                                                    _____       _____        _____        _____         _____
            Maturity level
                                                    _____       _____        _____        _____         _____
            Receives constructive criticism
                                                    _____       _____        _____        _____         _____
            Health
                                                    _____       _____        _____        _____         _____
Is there anything about this person that we should know before matching him/her as a mentor with this young person?



If you were in our position, would you, without hesitation, consider using this person as a Mentor for an “At Risk” Youth?



                                   No reference will be valid unless signed and with phone numbers.

Signature of person making recommendation                                                                   Date

Home Phone (         )                                                          Work Phone (______)_________________________

				
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